Affirmative Action: Where do we stand and where do we go from here?
2020 will go down in history for a lot of things, but perhaps more notably it will go down for the international and national conversations around racism, particularly institutional racism, that occurred during a pandemic. Internationally, the murder of George Floyd and the following Black Lives Matter protests began a global conversation about institutional racism and the role of the police in systemic discrimination. At home in Aotearoa, the continued minimisation of Māori academics’ work across the country’s academic institutions, and the proposition by senior health sciences leadership at the University of Otago to cap the number of Māori and Pacific students admitted to health professional programmes through the Mirror on Society Policy without consultation with senior Māori or Pacific leadership highlighted the need for critical conversations around racism in Aotearoa.
In late 2020 I began a literature review that sought to characterise the literature around affirmative action policies in health professional programme admissions, both within Aotearoa and internationally. Affirmative action is chronically under-theorised. When this is paired with strong and frequent attacks against affirmative action, there is a clear need for an evidence base that outlines what works and what we can learn to make sure that we are protecting and empowering affirmative action policies into our health professional programme admissions.
But what actually is affirmative action? What is its rationale in Aotearoa, and around the world? Why is it key to anti-racism work when looking at our health system?
These are questions I sought to answer when I first began my work. Despite the vast amount of evidence in this area, it was hard to find a clear definition of what affirmative action actually was. This definition from Guan (2005) gives a pretty good outline:
“Introducing measures to raise the participation and representation of members of population groups... where they have been historically excluded or underrepresented”
This definition focusses in on two important concepts when looking at affirmative action. The first concept is the concept of raising the representation of population groups in programmes, with the second stating that those groups have suffered from institutional discrimination. The two concepts speak to the ultimate goal of affirmative action in Aotearoa – creating a representative health workforce that can contribute to improving health equity for Māori, Pacific, Refugee, and low socioeconomic populations, where there is health inequity from historical and contemporary insitutional racism and/or discrimination. There is significant evidence to support that creating a representative health workforce has far-reaching benefits for equitable health outcomes.
The literature review pulled up international literature from across Australia, Canada, the United Kingdom, and of course the U.S. The vast amount of literature was spread across a number of different areas including what specific policies universities are implementing, their rationale, legal cases and what was successful and unsuccessful in these cases, as well as evidence and opinion based arguments, both for and against affirmative action policies. And across all these areas came three separate themes: The equity/equality dichotomy, the consequences of affirmative action bans, and the focus on academic achievement.
The Equity/Equality Dichotomy
Almost all of the literature from overseas struggled with the difference between what affirmative action meant from an equality versus an equity lens. American literature, in particular, focussed heavily on equality for “all people”. Much of the literature that opposed affirmative action admissions focussed on how medical schools should not be giving “preferential treatment” to certain population groups, and how providing affirmative action pathways for students based on race was actually being racist in itself.
An equality approach like the one taken in a lot of the literature does not look at the ultimate goals of affirmative action, including creating a more representative health workforce, or creating equitable outcomes for population groups. Instead, an equality approach seeks to maintain the status quo, regardless of the fact that ‘equal treatment’ is not a factual account of how Māori and Pacific are currently treated in the health system. This goes beyond sameness, with its connotations of assimilation, and moves toward wilful ignorance of what actually happens in our day to day operations of the health system and beyond, something that a representative health workforce can work to improve.
An equity approach, however, focusses on fairness of outcome and opportunity. Not just at the individual level, but at the institutional level too. This distinction is important to make because of the effect it has – when looking at the effects of institutional racism on our health workforce, including a lack of equitable representation and a direct effect on our health outcomes, the solution must be placed at the level where inequity occurs. Having an equity approach therefore is the only way to ensure we are being anti-racist at the institutional, or systemic, level.
The Consequences of Minimising Affirmative Action Programmes
It is important to note that affirmative action pathways into health professional programmes are just one way that equity in our health system can be acheived – there are countless other measures that continue to be taken, all of which are crucial to creating anti-racist change in our health system. However, if affirmative action policies were to be minimised or eliminated, what would happen to our representation?
This is a problem that much of the literature sought to clarify. One paper in particular made very clear the consequences of minimising or banning affirmative action policies into health professional programmes. The study followed the number of Black, Indigenous and Hispanic students that applied and admitted to Medical Schools in eight states, before and after an affirmative action ban was implemented. What the study found is that while the number of applications recieved by Black, Indigenous and Hispanic communities did not significantly decrease, the number of these students admitted to medical school the year after a ban was implemented dropped by 4.3%. Calculations proved that over the four years these admissions were followed, there was an almost 20% drop in the number of Black, Indigenous and Hispanic students admitted to medicine across the board.
So although the equality debate is used fiercely overseas to oppose affirmative action admissions into health professional pathways, more recent data proves that this approach does not work when looking at having a representative health workforce. In fact, the results from this study (as well as others) demonstrate that an “equality” approach can amplify the social stratification that we see in society through admission pathways, and as a result lead to admission pathways that exacerbate social inequalities – a manifestation of institutional racism.
The Focus on Academic Achievement – A Meritocratic Argument
A vast majority (if not all) of the international literature provided evidence for or against affirmative action by citing data that focussed solely on academic achievement of students who followed an affirmative action pathway as opposed to a “mainstream” pathway. There are two main problems with this that undermine affirmative action programmes.
The first is that many of these studies were done without the evaluation of opportunity structures, or as described by a 2010 paper as “the social, economic, and political structures that make success possible.” These structures however are not based solely on meritocratic criteria, and as a result create disadvantage regardless of merit or effort. This is another manifestation of institutional racism that impacts on the way we see applicants when they apply for professional programmes in Aotearoa. The structures that impact how well we are able to perform, including the school we were able to attend, our homes, our health, and even the way we are implicitly viewed, judged, and treated, have an impact on the ‘merit’ that makes it to some grades on paper. So while the literature may demonstrate that students who come into programmes on affirmative action pathways have lower grades, the effort to achieve these grades was most likely disproportionate to the effort a wealthy student, for example, may have made for higher grades.
Despite this, however, it should be said that this framing still paints a deficit picture of students that enter programmes on affirmative action pathways. What a meritocratic framing does in this situation is close our minds to what the real picture of affirmative action is – not just in Aotearoa, but around the world. One paper I read finally framed the issue in a way that actually aligned with the overall goal of affirmative action admission pathways in the first place: We should be providing communities with an equal opportunity to contribute, versus an equal opportunity to get in.
When looking at the reasons why we have affirmative action, we can see that the need is not based on our university cohorts – although representation in the classroom provides opportunities for better, more culturally safe learning for students and teachers alike – but on the representation in our health workforce, and the wider benefits this provides to our health system and to creating equitable health outcomes. Health professionals need to represent the communities they serve, otherwise we cannot hope to reach our goals, obligations of Ōritetanga, and truly anti-racist healthcare.
As an institution, representative of the Crown and therefore as Tāngata Tiriti, there is a duty not only to honour te Tiriti, but to be the “critic and conscience” of society. This means being vocal and steadfast supporters of anti-racist, pro-equity goals and strategies, both in affirmative action admissions but also whereever this may occur within the institution. For example, while equitable representation is being actively worked towards in our health workforce, only 3% of academic staff in Aotearoa are Māori. How can we as institutions say we are Tiriti partners and the “critic and conscience of society” if our own workforce is woefully unrepresentative and perpetuates institutional white supremacy?
Affirmative action admissions into health professional programmes are a fundamental part of our efforts toward health equity in Aotearoa. Universities have an opportunity to be world leaders in this area, and to create truly incredible change not only in the health system, but across sectors and within the institution itself. Jordan Cohen, the president of the Association of American Medical Colleges, was quoted in the early 2000’s telling Medical Universities to “beat back attacks on affirmative action, wherever they surface.” In 2021, institutions have a responsibility and an opportunity to push back against institutionally racist policy proposals, as well as inform a more aspirational plan for the future of affirmative action, and ultimately health equity in Aotearoa.
The first paper in our series looking at affirmative action is in the process of being publish